Management of intracoronary thrombosis complicating percutaneous transluminal coronary angioplasty

Abstract

Summary:With technological advances in equipment and increased experience of operators, the success rates of percutaneous transluminal coronary angioplasty (PTCA) now exceed 90%. However, acute periprocural occlusion continues to complicate approximately 6% of all procedures, and many of these occlusions are due to intracoronary (IC) thrombus.Patients at highest risk for this complication include those with acute ischemic syndromes or with angiographically apparent thrombus. These individuals may be candidates for the use of prolonged heparin infusions prior to dilatation, intracoronary thrombolytic therapy, or monoclonal antibody directed against the platelet glycoprotein IIbLIIa receptor. All patients undergoing PTCA should receive adequate antiplatelet therapy, including aspirin, and heparin with dosing monitored by activated clotting times (ACT). In addition, some recommend the use of ionic contrast material. When IC thrombus accumulates following intervention, initial therapy should include IC nitroglycerin followed by a combination of redilatation and IC urokinase infusion. Prolonged balloon inflations may be useful, particularly with the use of autoperfusion catheters. Platelet glycoprotein IIbmIa receptor antagonists may prove to be beneficial in this situation as well. If the patient's clinical status deteriorates in spite of these measures, emergency coronary artery bypass graft surgery may be required.

Pharmacological postconditioning with atorvastatin calcium attenuates myocardial ischemia/reperfusion injury in diabetic rats by phosphorylating GSK3β

“…Currently, ischemic events cannot be predicted in clinical practice; hence, ischemic and pharmacological preconditioning is less implementable. However, ischemic postconditioning has its own pitfalls; repetitive inflations and deflations of the heart during percutaneous coronary angioplasty may lead to coronary endothelial damages, plaque rupture or dislodgement, coronary artery rupture and intervention complications (20). Pharmacological postconditioning via a simulative endogenous protective mechanism (following ischemia and prior to reperfusion) is more practicable due to its effectiveness, safety and easy manipulation (8,21).…”

Analysis of Number Needed to Treat and Cost of Platelet Glycoprotein IIb/IIIa Inhibitors in Percutaneous Coronary Interventions and Acute Coronary Syndromes

“…1 Similarly, percutaneous transluminal coronary angioplasty, intracoronary stent placement, atherectomy, and other percutaneous coronary interventions (PCIs) are complicated by platelet activation that may lead to adverse events. 2 Platelet aggregation depends on activation of the glycoprotein (Gp)IIb/IIIa receptor, the final common pathway of platelet activation. 3 The receptor is necessary for platelet binding to fibrinogen, which leads to formation of a platelet plug and eventually to an intracoronary thrombus if left untreated.…”

Active site-inactivated factor VIIa prevents thrombosis without increased surgical bleeding: Topical and intravenous administration in a rat model of deep arterial injury

“…The doses of heparin used in our study are similar to those commonly used to prevent arterial thrombosis in animal experimentation 38,41,42 and to those used in clinical practice. [3][4][5]43 Also, we have shown that a reduction of the heparin dose below 1 mg/kg results in a loss of antithrombotic effect in this model (unpublished data). Thus, the increased bleeding cannot be accounted for by an excessively high heparin dosage.…”

“…Thrombosis is a serious complication in reconstructive vascular surgery and diverse forms of balloon catheter revascularization of arteriosclerotic vessels. [1][2][3][4] The classic periprocedural antithrombotic regimens, heparin and aspirin, and newly introduced agents such as GPIIb-IIIa blockers and hirudin all have the potential of producing serious bleeding events when given in effective doses. [4][5][6][7][8] Because these hemorrhagic effects relate to systemic anticoagulation, a logical approach to improve the safety score of antithrombotic strategies would be to target the therapy specifically to the treatment site with a locally active agent.…”